Thyroid cancer: When active surveillance is the best choice

Advances in cancer detection have saved many lives, but they have a serious drawback: Some cancers are being over diagnosed. This can lead to unnecessary treatment of tumors that never would have posed a threat if left alone.

A program at Memorial Sloan Kettering (MSK) gives some people with thyroid cancer that is at a low risk of growing and spreading the option of avoiding immediate surgery. Instead, patients can have their tumor followed closely — an approach known as active surveillance. NJ Advance Media recently asked Benjamin Roman, MD — a surgeon who cares for people with thyroid cancer at MSK Monmouth — to explain why active surveillance is often the best choice.

Q: Why is thyroid cancer being over diagnosed?

A: Back in the 1990s, the only thyroid cancers likely to be diagnosed were lumps doctors could feel with their hands. Since then, advances in imaging technologies, such as ultrasound, CT, and MRI, have revealed many small thyroid nodules that cannot be felt by touch. When doctors see these tiny nodules, they are often compelled to investigate further.

About one in 10 adults have a small low-risk thyroid cancer that’s not causing symptoms. This is usually identified as papillary thyroid cancer, which grows very slowly or not at all, and would never cause problems if left alone. But tens of thousands of people in the U.S. are over diagnosed and then unnecessarily treated for these types of cancers every year.

Q: What are the harms of over diagnosis and unnecessary treatment?
A: When someone learns that they have cancer, they often want it surgically removed as soon as possible. This operation is usually well tolerated, but all surgeries carry some risk. At MSK, the complication rate for thyroid surgery is very low because our surgeons are so experienced. Nationwide, however, about half of thyroid cancer removals are done by surgeons who perform fewer than 10 a year.

In addition to the potential harms of surgery, patients whose thyroid is removed typically need to take hormones for the rest of their lives. While most do fine on thyroid hormone replacement, about 10 percent to 20 percent say they feel fatigued and have to press harder to function at their normal level.

Q: What are the benefits of active surveillance? How does it work?
A: Active surveillance allows the patient to maintain his or her quality of life by avoiding the potential risks of surgery and hormone replacement.
While some patients require surgery, those who are candidates for active surveillance have an ultrasound every six months to see if there is any growth. If no growth is seen after two years, we space out the ultrasounds to every nine or 12 months.

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